eTELEMED 2014 : The Sixth International Conference on eHealth, Telemedicine, and Social Medicine
Approaching 2014: Is Telemedicine Assessed from The Social Perspective? A Brief 2013 Systematic Review Francesco Fusco, Leopoldo Trieste, Giuseppe Turchetti. Institute of Management-Management and Innovation (MAIN) Scuola Superiore Sant’Anna Pisa, Italy e-mail:
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[email protected] Abstract—Recent reviews in Telemedicine (TM) detected methodological flaws in economic assessment. Our brief review addresses the perspective adoption problem, investigating to what extent adopting a broader point of view could have an impact on TM economic studies and consequential diffusion. Out of 486 articles found, 15 studies were selected for full-text assessment. Most of them showed an improvement in methodology if compared with the past TM economic evaluations. However, only 4 papers reported data from the social perspective and among them 3 presented productivity loss. Although some positive results in economic evaluation were observed, to date it is not clear to what extent TM is paid for by third parties or has to be paid by the patients. Keywords-economic evaluation perspective; cost-effectiveness; cost-utility; review;
I.
INTRODUCTION
Telemedicine (TM) is a relative recently established field, nonetheless it is dominating the debate in the scientific community. Information and Communication Technologies (ICT) constant improvement resulted in various benefits for the users. In fact it should be considered the revolution in users’ life when the ICT reached a wide diffusion. In less than 30 years, the average consumer passed from barely communicating with Total Access Communication System (TACS), to gathering lap-top duties in smart-phones. This overturn in everyday lifestyle, completely changed habits and therefore the time spent in different daily life tasks. While mobile communications and Internet diffusion have already shown to have a positive effect on GDP and productivity growth, [1,2] the same could not be stated for telemedicine. In the global financial crisis setting, resources allocated to the healthcare sector were significantly diminished; this scenario asks for cost-saving initiatives, but also for innovative and effective strategies able to make the healthcare system financially sustainable. Within this framework, Medicare and Medicaid provided reimbursement for many telemedicine programs for preserving high quality healthcare and pursuing a cost-saving strategy in those areas where specialized employees are not available (e.g., rural districts) [3]. The forecasted market value for telecare was predicted to double from $9.8 billion (2010) to $27.3 billion (2016); 18.6% being the compound annual growth rate, having not substantial hinders on its growth [4].
Copyright (c) IARIA, 2014.
ISBN: 978-1-61208-327-8
Nevertheless, effectiveness and cost-effectiveness of telemedicine and its related fields are not clear yet. Both early and the most recent literature reviews [5-10] report contradictory results on the actual impact of telemedicine in terms of costs and effectiveness. However, most of the reviewers observed a high prevalence of poor designed and developed studies, probably responsible for reluctance in adopting telemedicine. In addition, it is not clear to what extent telemedicine should be considered an only third-party payer's matter or not. There is a common agreement about cost-utility analysis to be performed adopting National Health Service (NHS) perspective. Nonetheless, estimating only third-party payer's costs could be responsible for partial cost assessment, and consequential partial benefit estimation. NHS perspective disregards all patients’ related cost, excluding indirect and out-of-pocket costs. Productivity loss is a very controversial point in economic evaluation in healthcare. In health economics it was extensively discussed whether indirect costs (productivity loss) should be included in Cost-Effectiveness Analysis (CEA), without reaching a final and wide consensus [11,12]. The explanation for that could be found in the necessity for the NHS to optimize resource consumption as it is driven by spending cap issues. However, patients (and potential informal caregivers) perspective could consequentially report extra information able to influence society itself. Other issues frequently disregarded in economic evaluation are direct non-medical costs (i.e., travelling and accommodation expenditures), which account for a considerable amount of resources consumed if considering high prevalence diseases. The societal perspective is able to embrace all these costs, merging NHS costs (medical and not medical direct cost) to patient ones (out-of-pocket medical and non-medical direct cost; indirect and intangible costs). The object of our brief review is to investigate to what extent economic evaluations in telemedicine published up to 2013 were able to capture potential benefits considering the social perspective issue. The article is composed by five sections. Introduction addresses state of art and the systematic review aim. Methods section describes the procedures used to select the included articles. Results section explores and highlights the main findings. Discussion reports issues and possible solution to assess properly telemedicine. Finally, conclusion accounts for authors considerations.
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eTELEMED 2014 : The Sixth International Conference on eHealth, Telemedicine, and Social Medicine
II.
METHODS
In order to identify all published studies inherent to economic evaluation in telemedicine, a systematic review was conducted throughout the following databases: EBSCO host (Medline; Cinahl; EconLit; PsycInfo); Database of Abstracts of Reviews of Effectiveness (DARE); ISI Databases (Science Citation Index; Social Science Citation Index; Arts and Humanities Citation Index); Embase; NHS Economic Evaluation Database; Health Technology Assessment Database and the Cochrane Databases. The studies included in the review are full economic evaluations according to Drummond [11]; therefore, the following terms were included in the search strategy: Cost-Minimization Analysis (CMA), Cost-Consequences Analysis (CCA), CostEffectiveness Analysis (CEA), Cost-Utility Analysis (CUA), Cost-Benefit Analysis (CBA) of telemedicine and its explosion in mesh tree. Studies reporting only costs or only effectiveness were excluded. Other exclusion criteria were: email-only or telephone-only based studies and different languages than English. Results were limited to the period January 1st, 2013 to November, 2013, as previous reviews extensively reported and discussed data and methodological issues [8,10]. III.
RESULTS
Once identifying the article titles, duplicates were deleted using MS excel 2013 (Microsoft Corporation). 486 articles were obtained from search strategy terms research. After titles revision 451 articles were excluded because they were not economic evaluation. Abstracts revision has led to exclude 20 articles: 6 considered only cost, 4 were reviews, 3 considered only effectiveness, 2 were study protocols and 5 were excluded for other reasons (telephone based, different language than English, patients preference, validation study). After the abstract assessment, 15 articles were included for full-text evaluation (Figure 1). NHS and Social perspective were the most adopted respectively 10 and 4 studies. A. NHS perspective Among the included trials (Table I), the majority adopted the NHS perspective. The whole set of studies was assessing performance of telemonitoring devices in chronic diseases (Heart failure, Chronic Obstructive Pulmonary Disease, Diabetes, Hypertension), reporting in most of the cases utility outcomes (e.g., Quality Adjusted Life Years QALYs). Time horizon ranged from 6 months to 16 months. Out of 6 decision models (Table II), 4 of them were Markov model-based economic evaluation and 2 decision tree ones. Although most of them adopted a third-party payer point of view, QALY was chosen as effective outcome in 5 studies. The time horizon covered period ranging from 3 years up to lifetime. Beyond clinical trials and decision models, 2 out of 5 studies with various designs (Table III) assessed TM from the NHS perspective. The interventions were compared with results belonging to the same patients, but observed before telemedicine procedure started. No Health Related Quality of
Copyright (c) IARIA, 2014.
ISBN: 978-1-61208-327-8
Life (HRQOL) outcomes were considered; authors chose monetary benefits or clinical outcomes. B. Social perspective Most of the studies assessing costs alongside clinical trials adopted NHS perspective. Nevertheless, Zanaboni et al. [13] showed costs experienced by patients for travelling and private visits in both study arms; however, patients’ costs were excluded in CUA. No significant difference in cost for NHS was observed, on the other hand patients in TM arm experienced a lower expense of 100€ per patient/year (p0.05).
Direct non-medical cost: Travelling expenses Indirect cost: Productivity loss (assumption) Effectiveness Outcomes HbA1c level.
Cost reduction range: $9’430-$11’170 (TM vs UC). Effectiveness Outcomes: HbA1c level reduction: T2DM 7.4% (TM) vs 7.6% (DVDD) (p 0.05).
Personalized TM to check various health parameters. Control: TM patients data before enrolment (usual care).
Direct Costs: ER Visits, Hospitalizations, Length of Stay, Nurse Home Visits, Home telemonitoring. Effectiveness Outcomes: Assumption of noninferiority for TM respect to UC.
Total costs: Pre TM: $3’840 . During and after TM: $2’283. Effectiveness Outcomes: Assumed to be equal to UC.
Intervention: Web telemonitoring. Control: Usual care.
Direct costs: ED visits, hospital visits, and web monitoring nursing, travelling(assumption) Indirect costs: Productivity loss (assumption) Effectiveness Outcomes: ED accesses number. Costs: Medical expenditures Effectiveness outcomes: Days of treatment.
Cost: Web TM follow-up cost: €86.1 per patient during the first month of life. Hospital-based follow-up cost: €182.1 per patient during the first month of life. Effectiveness Outcomes: ED return rate: UC follow-up: 15.8%; TM: 5.6% (P=.026). ICER: -941.2€. Sensitive analysis: One-way: Varying ±75% the cost, Internet-based follow-up ICER was still in favour of TM. All diseases: Telecare had a negative coefficient for number of treatment day (p
